Escharotomy

After our last post, a few viewers have suggested that we continue the trend of elevated compartment pressures and address a super duper rare yet potentially life saving procedure today.   So, escharotomy....here-a we go!

Let's say you have a patient brought in from a fire with full thickness burns to their torso.  You intubate, start hydrating per the Parkland Formula, and you (assuming you are not one) get your burn center on the horn.  Your respiratory tech suddenly notes that they are having an incredibly difficult time ventilating patient, and their peak pressures are shooting off the charts.  Your trauma surgeon is not readily available, but you need to do something now.  

It's time for escharotomy, as the full thickness burns are causing chest wall constriction.  Eschars can also cause peripheral arterial occlusion (not unlike compartment syndrome!), and tracheal compression as well. 

The pressure needs to be released in a fasciotomy-like release, and almost always this should be done in an operating room--if there's time.  The procedure itself really does creep outside of the scope of our practice, and really should only be done in absolutely dire circumstances, mainly airway compromise and severe limb ischemia.  

To prepare, you will mainly need some antiseptic prep and a scalpel.  It will be handy to have electrocautery (cutting diathermy for the skin and coagulative diathermy for bleeding) available as you may encounter some significant bleeding.

The incisions to the chest should start at the clavicles at the anterior axillary line and extend inferiorally, down to the subcutaneous fat.  You'll want to connect these lines with a transverse incision in the upper abdomen (the so-called "Roman Breast Plate"). If your pressures were significantly elevated you should see notable separation between the wound edges. If it's indicated, extremities can be incised in a similar manner along medial and lateral mid-axial longitudinal lines as depicted below.  You'll want to avoid any extensor or flexor creases.

If the burns are full thickness, the skin should be insensate but local anesthesia may be indicated if there's a question if it's partial thickness or not.  Overall optional as your patient is hopefully intubated and sedated at this point, and you may not have the time.

A very creative, MacGyver-esque simulation model can be seen here courtesy of Greater Sydney Area Helicopter Emergency Medical Service.

As always, these procedures are meant for medical professionals, and are for EDUCATIONAL PURPOSES ONLY.  All efforts should be made for this one to be done in a controlled, operative setting with trained sub-specialists, and not in your shop.

Sources:

Roberts and Hedges Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 38.

Life in the Fast Lane Blog - "Releasing the Roman Breastplate"

Compartment Pressure Measurement - "Stryker" It!

Let's say you have a middle aged otherwise healthy patient who, after throwing back a few cold brewskis, decides to "kick it" with a group of skateboarding youths.  We'll cut to the chase and state that it doesn't go well, he's now in your ED, and his left calf doesn't look too hot.  Maybe he's got a tibial fracture, maybe not.  Either way his leg is tense as can be, and despite getting an adequate dose of narcotics he is in E-X-Q-U-I-S-I-T-E pain.  You do an exam, and note a tense extremity with pain with passive stretch, some decreased sensation, but has a good distal pulse.

Just like Lloyd Bridges in Airplane, you should be shouting, "Stryker! Stryker! Stryker!"  Stryker needle that is (it's the most commonly used product, so we'll only refer to that one), to rule out compartment syndrome.

The condition can occur in any extremity, but the most common presentation you'll see is the one stated above.  It is an incredibly difficult diagnosis to make clinically, and it is a huge potential pitfall as correct identification can be delayed or even missed entirely.  An interesting cohort study from the Canadian Journal of Medicine noted that patients at a hospital in Montreal who underwent fasciotomies noted a concerning "median event-to-operation" duration of 9 hours for traumatic cases and a shocking 34 hours for nontraumatic cases.

We are always taught the classic 5 P's (pain/swelling, pallor, paresthesias, paralysis, pulselessness), but if you're noting these findings the cat is already out of the bag, and your patient will likely have permanent deficits as a result.  If it's early, you'll have to trust your gut and go check the pressure.

The set-up for this one is pretty simple, and everything you'll need should be in the pre-packaged kit.  It includes a side ported needle, a diaphragm chamber, a prefilled 3 cc syringe, and the main monitoring unit.  It is possible to jury rig a set-up to continuously transduce pressures like an arterial line, but it's beyond highly unlikely you would ever need to do this in the ED (more tailored for either the OR or a surgical ICU), so we will not cover that today.

Connect your needle to the diaphragm, and then screw in the syringe on the other side.  Load this assembly by pushing it into the monitoring unit, with the black side of the diaphragm down.  Snap the cover closed gently.  To calibrate, hold the entire unit up at a 45 degree angle, and flush it to get the air out.  Push the monitoring button to turn it on, then hold the monitor at the angle you're going to "Stryker at" and hold the zero button down.  You should see "00" appear.

Then you'll need to identify the appropriate site to target.  It all depends on where you think the affected compartment is.  For sake of discussion, and since it's the most common one, we'll focus on the anterior compartment of the calf.  Here, you'll identify the area where the proximal and mid thirds of the tibia meet, and then move 1 cm lateral to this.

You'll want to give them adequate local anesthesia at the site of injection, but you need to take care not too inject too deeply so that you get a falsely elevated reading. Once this is done and the area has been properly cleaned, insert your needle 1-3 cm into the compartment, and then, very, very slowly inject like an aliquot of saline (they state no more than 0.3 cc) and wait for the reading to appear.

If the pressure is greater than 30 mmHg, or within 30 mmHg of the diastolic blood pressure, your patient needs to be evaluated for a fasciotomy.

SoBroEm.com also features a nice step by step illustration here.

Here's another demonstration of the assembly and procedure from the Plastic Surgery Project:

If you haven't had a chance to check out the YouTube page of Dr. Nabil Ebraheim, go NOW.  He's a veteran orthopedist with some incredibly high yield videos.  Here's his clip on compartment syndrome (goes out of our scope but still a good watch):

As always, these writings are for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. This is probably one of the least invasive procedures we've covered thus far, but that doesn't mean you should go running into a patient's room to needle their calf.

Sources:

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 54.

Messina et al.  A human cadaver fascial compartment pressure measurement model.  J Emerg Med. 2013 Oct;45(4):e127-31. 

Vaillaincourt C. et al.  Quantifying delays in the recognition and management of acute compartment syndrome.  CJEM. 2001 Jan;3(1):26-30.

Dr. Nabil Ebraheim's YouTube Page

Plastic Surgery Project YouTube Page

SoBroEm.com